What is the ICD‑10‑CM code for a tooth infection that develops after a dental extraction?

ICD-10-CM Code for Post-Extraction Tooth Infection

The appropriate ICD-10-CM code for a tooth infection developing after dental extraction is K04.7 (Periapical abscess without sinus) or T81.4XXA (Infection following a procedure, initial encounter), depending on whether the infection represents a continuation of pre-existing dental pathology or a true postoperative complication.

Primary Coding Options

K04.7 - Periapical Abscess Without Sinus

• Use this code when the post-extraction infection represents an exacerbation or continuation of pre-existing odontogenic infection that was the original indication for extraction 1
• This is the most common scenario, as periapical exacerbated infections, especially in the molar region, are the most frequent cause of odontogenic infections requiring intervention 1
• Apical periodontitis accounts for 46.9% of severe odontogenic infections requiring hospitalization 2

T81.4XXA - Infection Following a Procedure, Initial Encounter

• Use this code when the infection is a true postoperative complication occurring in a previously uninfected extraction site 1
• Postoperative infections after tooth extraction (OITR) represent a distinct category from exacerbated dental infections 1
• Mandibular tooth removal, particularly retained lower wisdom teeth, leads to a significant number of postoperative infection cases 1

Additional Relevant Codes

K04.6 - Periapical Abscess with Sinus

• Use when the post-extraction infection has established a draining sinus tract 3
• Clinical signs include visible fistula formation in the oral cavity 3

M86.8X9 - Other Osteomyelitis, Unspecified Site

• Use if the post-extraction infection progresses to bacterial osteomyelitis of the jaw 4
• This severe complication occurs in approximately 3.7% of dental abscess cases, particularly following primary tooth extraction during acute infection 4
• Risk factors include diabetes, use of clindamycin, and transcutaneous incision 4

Clinical Documentation Requirements

To support accurate coding, document the following specific details:

• Timing relationship: Specify whether infection was present before extraction or developed afterward 1, 2
• Anatomic location: Identify the specific tooth site and whether infection has spread to adjacent structures 5, 6
• Severity indicators: Note presence of facial swelling, trismus, systemic symptoms, or airway compromise 3
• Treatment provided: Document drainage procedures, antibiotic therapy, and whether extraction was primary (during acute infection) or secondary (delayed) 4, 2

Common Coding Pitfalls

• Failing to distinguish between pre-existing infection that prompted extraction versus true postoperative infection—these require different codes 1
• Underestimating severity: Not coding for complications like osteomyelitis or spreading infection when present 4
• Missing the procedural relationship: Not using the T81.4XXA code when infection is clearly a procedural complication 1
• Inadequate specificity: Using unspecified codes when clinical documentation supports more specific diagnosis 2